Kids misbehaving: ADHD or just naughty?

SINGAPORE - Children who misbehave or fall behind in their schoolwork used to be called 'stupid', 'lazy' or just 'naughty''.

Now, there is a whole slew of medical terms to describe various types of childhood behaviour - autistic spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), sleep disorder (SD), oppositional defiant disorder (ODD), Asperger's syndrome and Tourette's syndrome.

Research and improved diagnostic techniques have led to a growing awareness that kids 'acting out' might not be just a normal symptom of growing up or teenage angst. There could be some kind of kink in the mental make-up which, when identified early, can be treated.

Increasingly, child psychiatrists are getting children referred to them by parents and teachers who believe there is this kink causing their children's unusual behaviour.

The Child Guidance Clinic at the Institute of Mental Health (IMH) saw more than 840 new cases of ADHD last year - almost four times the number treated in 2000.

Dr Daniel Fung, who heads the child and adolescent psychiatry department at IMH, said about 30 per cent to 40 per cent of these young patients were referred directly by their schools.

The IMH is working with schools and other groups to spot children with ADHD for treatment. The Education Ministry is equipping teachers with a basic know-ledge of mental health.

It is good that parents and teachers are aware of behavioural or learning disorders such as ADHD - because there are children who genuinely need help.

Girls with ADHD, for example, are often overlooked as the condition is usually associated with boys.

A teacher in an all-girl secondary school recalled how one of her students was openly defiant and moody and often had bouts of anxiety. The student's ADHD went unnoticed for years, until she was diagnosed in her late teens and put on medication. She is now doing well at a tertiary institution.

All that is well and good, but sometimes, a little knowledge can be a dangerous thing.

Over-diagnosis

There are some who may be quick to over-diagnose ADHD - or even use it as a crutch to explain away any form of under-achievement.

Dr Fung said that 10 per cent of all new cases at IMH are diagnosed as not having any mental health disorder. Last year, this comprised nearly 300 of the new cases.

A mother related how her seven- year-old daughter was referred to a psychiatrist for ADHD, which is characterised by hyperactivity, impulsiveness and inattention. The girl's teacher said she could not sit still throughout a single lesson when she was in Primary 1.

But it transpired that the child had been through the Montessori method of learning, which focuses on sparking her interest in learning through discovery rather than by rote. In other words, she was inattentive because she was bored. A change in teaching techniques would have sufficed. There was nothing wrong with her.

Children develop at different rates and sticking labels on them, medical or otherwise, might do more harm than good, said Dr Adrian Wang, a psychiatrist in private practice. 'Naughty'' children might well grow up into well-behaved teens, with proper parental guidance.

Another mother brought up the case of her five-year-old, who was deemed by his teacher to have Asperger's syndrome - a form of autism characterised by social isolation, obsessive and repetitive behaviours. One sign: He preferred books to playing with his peers.

After worrying for a month, his mother consulted an expert in child development.

He was then diagnosed as gifted.

Worldwide, ADHD is present in 3 per cent to 5 per cent of children. These children are treated with Ritalin, which is so widely used in the United States that it is also known as 'kiddy cocaine'. In some parts of the US, one in 10 schoolchildren is on Ritalin.

In most cases, side effects such as nervousness and insomnia are mild. But temporary growth suppression has been reported if the drug is used long-term.

Here in Singapore, at most 70 per cent of patients improved with Ritalin. Traditional Chinese medicine practitioners are also testing out herbal potions as the alternative answer, it was reported recently.

It is understandable that parents, especially those in developed countries who have fewer children, are concerned about their child's development and want the best treatment possible.

The danger is in thinking that medicine is the key to childhood ills.

Over in the US, the concern doctors have is that too many children in the country - especially boys who are merely rambunctious - are being given the drug after cursory evaluations.

Much therefore depends on parents making informed decisions, aided by child experts who give them as much information as possible.

Sometimes, this might mean a good hard look at their own parenting skills or acknowledging that their children are simply very, very naughty and might well belong to an institution with a tough regime to set them right.

Doctors say that behavioural problems in children are not totally due to ADHD. Poor parenting skills need to be blamed as well.

Sometimes, a good spanking instead of a lifetime on drugs might well do the trick.

This article was first published in The Straits Times.

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